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Based on interview, patient record review, and facility policy review, the Critical Access Hospital (CAH) failed to follow their advanced directive policy for five of 10 medical records (Patient (P) 2, P5, P7, P9, and P10); and failed to follow their policy on signing consents for one of 10 patients (P3) reviewed. The CAH's failures have the potential to affect all patients seeking services in the emergency department (ED).


Findings Include:


1. Review of policy titled, "Advanced Directives," dated 12/24/19 revealed, "An initial inquiry about advanced directives is completed by nursing staff caring for the patient when admitted to GRMC (Goodland Regional Medical Center). Admitting personnel will document in the medical record whether the patient has a completed an advanced directive and that information concerning advanced directives has been given to the patient/significant other during the admission process."

Patient 2

Review of P2's emergency department (ED) record dated 10/18/21 showed the ED triage nursing note did not include documentation to indicate whether P2 had an advanced directive or not.

During an interview on 10/26/21 at 2:30 PM, Clinical Informatics Analyst (CIA) 6 confirmed Triage Nurse (TN) 8 was responsible to document if the patient had an advanced directive, or if they wanted them. CIA6 confirmed there was no documentation in P2's ED record dated 10/18/20 about advanced directives.

Patient 7

Review of P7's emergency department (ED) record dated 01/03/21 showed the ED triage nursing note did not include documentation to indicate whether P7 had an advanced directive or not.

During an interview on 10/26/21 at 2:40 PM, CIA6 confirmed the Triage nurse was responsible to document if a patient has an AD, or if they want them. CIA6 confirmed there was no documentation in P7's ED record dated 01/03/21 about advanced directives.

Patient 5

Review of P5's emergency department (ED) record dated 05/08/21 showed the ED triage nursing note did not include documentation to indicate whether P5 had an advanced directive or not.

Patient 9

Review of P9's emergency department (ED) record dated 05/01/21 showed the ED triage nursing note did not include documentation to indicate whether P9 had an advanced directive or not.
Patient 10

Review of P10's emergency department (ED) record dated 09/02/21 showed the ED triage nursing note did not include documentation to indicate whether P10 had an advanced directive or not.


During an interview on 10/27/21 at 8:30 AM, Chief Clinical Officer (CCO) 3, CCO3 stated that the Triage nurse was responsible to obtain the advanced directive information from the patient during the triage process. CCO3 stated that patient records for P5, P9 and P10, did not follow policy, and that the Triage nurse did not document advanced directive information for these patients. CCO3 confirmed that it was not documented anywhere in the ED records.


2. Review of the facility's policy titled, "Consents," dated 08/05/19 revealed, "If the patient is unable to sign (i.e., due to injury to hands, inability to write, or severe illness), but gives verbal consent, the stamp "Patient unable to sign due to mental/physical condition" may be used or patient may make X. In either case two witnesses must sign the consent. This could be a relative and qualified hospital employee."

Patient 3

Review of P3's ED visit record dated 12/27/20 showed P3's chief complaint was listed as unresponsive. The Qualified Medical Professional (QMP) determined P3 required a higher level of care and a transfer was arranged. Review of P3's transfer record only identified one signature on the transfer consent and required two signatures.

During an interview on 10/26/21 at 2:40 PM, the Clinical Informatics Analyst (CIA) 6 stated that when a patient is unable to sign the transfer record, two witness signatures were required. CIA6 confirmed P3's transfer consent only had one witness signature.

Based on record review and interview the Critical Access Hospital (CAH) failed to ensure the medical record had accurate information for one of 10 (Patient (P) 1) reviewed. Failure to ensure medical records have accurate patient information has the potential to affect the future health care and services patients receive.


Findings Include:


1. Review of P1's ED medical record dated 10/27/20 showed the triage nursing record listed P1's chief complaint listed as "suicidal ideation." However, review of nursing notes, physician notes, and assessments, showed P1's chief complaint for being seen was a fever.


During an interview on 10/27/21 at 8:15 AM, Chief Clinical Officer (CCO) 3 confirmed P1's chief complaint was for a fever but was not sure why suicide ideation was listed. CCO3 confirmed nothing in the visit dated 10/27/20 indicated P1 was suicidal.

During a telephone interview on 10/27/21 at 9:26 AM, Physician's Assistant (PA) 7 who cared for P1 on 10/27/21, stated P1 was being seen for fever. PA7 stated that the facility P1 lived in had COVID-19 going through the facility. PA7 stated P1 tested negative but continued to have a fever and was sent to the ED. PA7 confirmed P1 was not suicidal during this visit. PA7 stated the suicidal ideation entered by the Triage Nurse (TN) 8 is automatically populated for all subsequent ED records during the visit.


2. Review of P1's ED medical record dated 10/27/20 showed the triage nursing record indicated TN8 documented P1 did not have an advanced directive. However, review of complete record confirmed there was an advanced directive on file

During an interview on 10/26/21 at 2:30 PM, Clinical Informatics Analyst (CIA) 6 stated that the triage documentation on 10/27/21 was inaccurate and a copy of the patient's advance directive was in the patient's medical record.